Hospital bill for 25k not covered by Medicare

[bmcgonig]

I was thinking the same thing... they usually just tell you that you need to stay overnight and that they are moving you to a hospital room.

I guess that you need to know enough to ask whether you are being admitted or kept over for observation and if the latter then object.

That said, they could tell you that you are being admitted and you could find out later that it was only observation... and they could just claim that there was a misunderstanding or miscommunication.

Even if the doctor admits you, that can be later reversed by admin.

 

[SkisALot]

I read that as of Nov. 1, 2019 this kind of billing was illegal but if the info is true, it wouldn't surprise me that hospitals do it anyway. My suggestion is for the OP to contact Medicare.
DH and I have horrible experiences with hospital billing including being turned over to collection for a bill we never received. Recently we received a bill for $34,000.00 because of a doctor's office billing error (Medicare wouldn't pay.). After months of fighting both, the bills have been resolved, but it took vigilance on our parts.

Correction (and yep, I'm quoting myself!): I meant to say as of Nov 1, 2018 not 2019.
Additionally I agree with others that Medicare A & B offers doctor choice over an advantage plan. If we hadn't been able to choose a doctor for DH some years ago he would be dead.

 

[GladToBeFree]

Another scary thing I learned on this thread is that supplemental insurance people buy in addition to Medicare doesn't help either if Medicare doesn't accept the charge to begin with. I thought the idea of buying supplemental insurance (I don't know what kind) is in order to cover all the rest of medical expenses that Medicare doesn't cover.
.

I'm amazed at the number of horror stories here. I have a popular medicare advantage plan that describes two situations, In network and out of network charges. However if you read the details, both are covered at the same rate. I do have to make sure they accept medicare but with the number of people that are on medicare, there aren't any that I've encountered that don't.

Some years back I was presented with the form that said I had to pay for anything that the insurance didn't cover. I wrote on it that I would only pay deductibles and the doctor came in and essentially told me to take a hike.

Jim

 

[Bongleur]

The author was provided with a MOON notice, required for observation stays over 24 hours. The notice is required even if the person only has Part A.

The concerns about observation and original Medicare revolve around patients being transferred to a SNF. The SNF stay would not have been covered because it requires a prior 3-day inpatient hospital stay.

how many pages/words is this notice? what grade level comprehension is required? How much does being sick in bed further degrade reading comprehension? Sounds like a lawyer/politician document not for the real world.

What is SNF?

 

[travelover]

I read that as of Nov. 1, 2019 this kind of billing was illegal but if the info is true, it wouldn't surprise me that hospitals do it anyway. ............

It didn't happen. https://www.buzzfeednews.com/article/paulmcleod/surprise-billing-deal-richard-neal

 

[JoeWras]

What is SNF?

Skilled Nursing Facility

 

[EastWest Gal]

Back to the original article. There are certain diagnoses that are ALWAYS inpatient. Surgical procedures that require extensive care afterward, regardless of length of stay, are inpatient admissions. Newborns are always inpatient admissions, as are admission for delivery. Radical prostatectomy seems to fall under this category. Medicare does not reimburse for a radical prostatectomy as an outpatient/observation status because it reimburses the procedure as an inpatient. The 48 hour rule does not apply to these procedures, but hospital administrators and billers frequently erroneously bill these as observation status, if the stay is two midnights or less, regardless of the diagnosis or procedure. They do this simply to get more money, IMO.

It's a horrible system. But the it does not appear that the patient, who was a physician, ever contacted Medicare and complain about the bill.

This document shows that-check pages 2 and 3.

https://www.bostonscientific.com/co...rostate-Health-Coding-Payment-Guide_FINAL.pdf

On page 2, this document lists the Medicare reimbursement rate for "outpatient radical prostatectomy" as N/A (not applicable) and then on the next page the document lists the reimbursement rate for inpatient radical prostatectomy. The hospital was wrong to bill as an outpatient. The patient can probably complain to Medicare. The problem is one of the rampant problems in medical billing I saw over and over again.

I got into yelling matches with colleagues over this stuff the last couple of years that I worked because doctors and hospitals only know the 48 hour rule and not diagnosis driven inpatient vs outpatient rules.

When I started practice, there was no such thing as observation status. That started in the 1990s with a major change in evaluation and management coding. First it was 23 hour observation status. Then somewhere in the last 10-15 years it changed to 48 hours for Medicare/Medicaid, and the insurance companies soon followed. Meanwhile healthcare costs go up and up, all paid for by the patient through premiums, copays, and deductibles. The insurance companies do not fight egregious charges; they just raise the rates.

But I don't understand why this doctor never complained to Medicare. They have a hotline for such issues. He might have won and got the bill reversed.

 

[aja8888]

I've been on Medicare with a supplement for 13 years. When is this madness going to end?

I'm not going to tell the stories, but I have had my supplemental insurance company refuse to process claims until I FIGURED OUT where the billing mistake was that caused them to overpay my Medicare deductible by $20 on a $100,000 surgery. It took me 6 MONTHS and dozens of phone calls and letters to find the coding culprit (who was in India).

Oh, in case you haven't figured this out yet, ANY billing mistakes made by doctors, clerks, admin staff, billing services, hospitals, labs, etc, are ON YOU to figure it out and try to fix it. (and you had no part in the process)

This is NUTS!

 

[pb4uski]

I totally agree. The system is broken beyond all repair. Drastic change is needed because it is hard to imagine that anything that is done would make it worse. Medicare for all is worth a try... or nationalize all medical service providers and pharmacuticals.

 

[Old Microbiologist]

RetMD21 - Imagine you go to a clinic or hospital and show your National medical card and that is the only time required. No signatures or anything and no copays..nothing at all. Everything is completely free from that point on. All it costs is $25 a month. In Hungary the average monthly income is $830 (250,000 Hungarian Forints) so you have to keep it in relative perspective. Still, it is a bargain compared to the US.

I remember way back when I got my first mortgage in 1972 I had to qualify for the loan. I recall the calculations included living expenses but didn't include health care costs at all. Now health care costs are 30% of income so something has gone wrong since 1972. What bugs me is it is like boiling a frog by slowly heating the water, we have gradually come to this point where people accept these expenses as normal. What we should be seeing is mass protests but what we see is complacency. I really don't understand how it is that this isn't happening in the US.

 

[yclipse]

I found this February 2019 article from the Hospitalist that notes that a radical prostatectomy done via laparoscopic technique was removed from the "always inpatient" list in early 2018.

https://www.the-hospitalist.org/hospitalist/article/194971/medicares-two-midnight-rule/page/0/2

 

[JoeWras]

I've been on Medicare with a supplement for 13 years. When is this madness going to end?

Not anytime soon when you have powerful congress people burying a bill that had wide support and was close to passing.

Looks like we're in for a long, long haul.

 

[JoeWras]

I totally agree. The system is broken beyond all repair. Drastic change is needed because it is hard to imagine that anything that is done would make it worse. Medicare for all is worth a try... or nationalize all medical service providers and pharmacuticals.

I lean libertarian, but maybe I'm not a real one, because I'm kind of agreeing with you on this vital service.

Universal medicare will also get the wrath of Gen-Z on the butts of our lawmakers when Gen-Z's get hosed by their "observation status" broken femur operation. They'll get mad and march while we sleep. At least we'll all be in agreement on a cross-generational challenge.

 

[SkisALot]

It didn't happen. https://www.buzzfeednews.com/article/paulmcleod/surprise-billing-deal-richard-neal

Thank you. While it's bad news I'm glad I'm aware of it. I researched it but didn't find that article.

 

[fh2000]

It didn't happen. https://www.buzzfeednews.com/article/paulmcleod/surprise-billing-deal-richard-neal

Is this the Balance Billing law already in some states, including California, except this is designed for the whole country?

"Balance billing regulation has been going on in California for well over a decade. ... 1611 is the California Legislature's latest attempt – this bill would prohibit a hospital from charging insured individuals more than the in-network cost-sharing amount for emergency and post-stabilization care."

 

[SkisALot]

I totally agree. The system is broken beyond all repair. Drastic change is needed because it is hard to imagine that anything that is done would make it worse. Medicare for all is worth a try... or nationalize all medical service providers and pharmacuticals.

Can you imagine how much longer it would take to see a doctor if everyone was on medicare? Already in California (and New Mexico I hear) you almost always see an NP, not a doctor, and that was after months of waiting. Our doctor friends in Calif tell us that they will retire if Medicare for all goes into effect. We haven't tried seeing a doctor here in Idaho yet. Don't know what that will entail.
But I do agree that the system is broken.

 

[RetMD21]

RetMD21 - Imagine you go to a clinic or hospital and show your National medical card and that is the only time required. No signatures or anything and no copays..nothing at all. Everything is completely free from that point on. All it costs is $25 a month. In Hungary the average monthly income is $830 (250,000 Hungarian Forints) so you have to keep it in relative perspective. Still, it is a bargain compared to the US.

Seems very straightforward. I don't understand why the US couldn't at last get a universal price list. Even if higher than Medicare by some factor it would be better than the current chaos. Also physicians and others are spending a lot of time doing unproductive things because of billing and hospital mandates.

I never understood the big lab director fees. Somehow that went away. Now the director is a hospital employee on salary. Got to to to an elaborate Christmas party years ago sponsored by a lab director.

 

[RetMD21]

I found this February 2019 article from the Hospitalist that notes that a radical prostatectomy done via laparoscopic technique was removed from the "always inpatient" list in early 2018.

https://www.the-hospitalist.org/hospitalist/article/194971/medicares-two-midnight-rule/page/0/2

Part of the game. The hospital could get in real trouble for billing inappropriately but taking advantage of the rules helps the bottom line.

Of course, this is a completely separate issue from balance billing.

Medicare for all could result in a lot of white collar job losses. Reviewing claims, rejecting them, arguing with doctors.

 

[Just_Steve]

Is this the Balance Billing law already in some states, including California, except this is designed for the whole country?

"Balance billing regulation has been going on in California for well over a decade. ... 1611 is the California Legislature's latest attempt – this bill would prohibit a hospital from charging insured individuals more than the in-network cost-sharing amount for emergency and post-stabilization care."

In NY also.


"The insurance company pays a small part of the bill, and the doctor sends the patient a bill for the rest (often called a balance bill). Under New York's law, the patient is held harmless, meaning she only has to pay as much of her deductible, copay or coinsurance as she would if the doctor were in-network."

 

[N02L84ER]

WRT balance billing, is the patient held harmless if the hospital is out of state?

 

[Just_Steve]

WRT balance billing, is the patient held harmless if the hospital is out of state?

I doubt it.

 

[6miths]

Can you imagine how much longer it would take to see a doctor if everyone was on medicare? Already in California (and New Mexico I hear) you almost always see an NP, not a doctor, and that was after months of waiting. Our doctor friends in Calif tell us that they will retire if Medicare for all goes into effect. We haven't tried seeing a doctor here in Idaho yet. Don't know what that will entail.
But I do agree that the system is broken.

Actually maybe not. If it were truly universal healthcare then it might be the only game in town. This was exactly what doctors in Canada said before the transition was made. What followed was the realization by MDs of just how much better the new system was. Instead of sometimes not getting paid or being paid with barter every bill was paid in a timely fashion with no delay or complex negotiation with a third party whose main goal was to pay the lowest possible price. Doctors did not and would not quit. And many would be happy to see the massive insurance and hospital bureaucracies dramatically scaled back and paid more appropriate salaries. Much of the incredible gaming of the system which seems to happen at every level in the US would likely also dramatically decline.

There is a great peace of mind that comes with not having to worry about how you, your family and friends and your fellow man are going to obtain quality health care.

 

[travelover]

...........There is a great peace of mind that comes with not having to worry about how you, your family and friends and your fellow man are going to obtain quality health care.

Oh sure but what about the death panels we were warned about?

 

[6miths]

Oh sure but what about the death panels we were warned about?

Oh yes for sure - small price to pay though. When that crystal on your hand turns red/black it's time to go.

 

[jjuneau]

My hospital billed $140,000 for a prostatectomy. Medicare paid $32. We spoke with the billing dept of the hosp. They said they had to accept that as payment. We paid $0.

Anyone who thinks government run health care can work is in fantasyland. Lots of folks just see that the bill has been paid and they owe little or nothing without paying attention to what actually transpired. Medicare is rife with fraud, inefficiencies, and mistakes. Even when nothing goes wrong, doctors and hospitals don't receive enough to get by without the income they get from other sources.